Significance and consideration of scar revision surgery to improve the quality of life and psychological health of patients. Brief introduction to histological components of scars and factors to be considered with regard to affordability and suitability of scar revision surgery in different types of scars. Historical information including why the treatment of scars is necessary and a summary of the evolution of scar revision techniques. Brief overview of subsequent sections.
A scar can be taken as an indicator of a traumatic process of wound healing. Scars, on the face and body, may not significantly affect the health of the patient, but they do affect their daily life activities and can become an obsession for many people. It is also not just an external medical problem, but a psychological impact on people. Contrary to the process of healing healthy skin, scars contain collagen that is different from normal skin. Various treatments and medications concern the collagen of the skin. Also, the aesthetic improvement of scars to improve the appearance and quality of life is important to a patient; scar revision surgery can be recovery only. Scar revision is generally suitable for atrophic, hypertrophic, and keloid scarring, but it can include other problems that are important. Different scars have a different cause, healing, results, extent, and structure; the objects that suit scar revision surgery and the time of selection too will be different. In deciding surgical skill/treatment method and giving medical evaluation and answer to patients’ requests, the surgeon always has to consider the availability.
Modern surgery, as we recognize it, was born in the middle of the 19th century and developed throughout the 20th century with the premise that the treatment of wounds and burn injuries applied different pathophysiology than the treatment of their late scar sequelae; hence scars were avoided.
A number of factors contribute to the overall suitability of a person for undergoing scar revision surgery. They include – among others – the type of scar, the size of the scar, the age of the scar, the patient’s skin type, the patient’s anatomy, and any prior treatments performed. Factors that may make a patient unsuitable for scar revision surgery include, but are not limited to, systemic disease that could impair or prolong the healing process, keloid or hypertrophic scars, or skin type or skin quality that decreases the likelihood of significant improvement following surgery. Being generally healthy along with avoiding smoking can significantly increase a person’s suitability for scar revision surgery.
Patients with scarring remain actively changing with time. Hypertrophic and keloid scars can slowly increase in size over several months. It is recommended that surgical treatment should be delayed until optimal healing is confirmed and the scar’s growth is no longer active. Furthermore, when considering revision, in the case of a traumatic event leading to the scarring, the patient’s emotional state should be assessed to see whether any surgical intervention is appropriate. In addition, the age of the scar can influence surgical decision-making and of course, the size of the scar is also an important aspect. Recovery can involve swelling, bruising, and discomfort, and complete recovery depends on the size and quality of the scar revision surgery.
Once you have undergone a successful scar revision surgery, there will be a notable improvement in the appearance of the area. Aftercare will be provided on the day of the surgery and for the duration of the healing process. This will include dressings and advice on mobility, as well as follow-up check-ups to ensure the area is healing properly and that sutures are removed where necessary.
During the recovery process, it is likely that there will be some swelling and bruising of the area. This can last for up to two weeks. It is common for patients to experience some pain, which can be managed with over-the-counter medication such as paracetamol and ibuprofen. There can also be changes to the sensation of the skin on the treated area while the nerves are healing – this could present as a numb or tingly area. Stitches will generally dissolve on their own, but external stitches will usually be removed 3-7 days post-operation in a follow-up appointment. While the area is delicate, it is highly recommended that patients use a broad-spectrum SPF 50 that’s suitable for sensitive areas when going outside during daylight. As long as they are consulted, swimming can be resumed two weeks after the stitches have been safely removed. You will need to follow up with your surgeon in person or send photos in order to monitor the scar and healing for a good few weeks following surgery. Our nurses are available for any questions or concerns between appointments. A complete recovery will take a longer time, usually the upper end of 12+ months.
Aftercare follows the completion of the procedure, focusing on what will be required in terms of ongoing maintenance and care for the newly revised scar site. Patients may need to use a medicated ointment or new scar management products. At this point, plastic surgeons may schedule follow-up appointments in order to assess the site and determine if any long-term adjustments or special aftercare protocols are needed for that individual. The recovery period covers anything from a few days to a month. Some of the things to expect during this time include the use of dressings, bandages, or garments. In most cases, the return to work or activity can occur about a week after the surgery. Dermabrasion results in a 7 to 10-day recovery period.
Plastic surgeons may also recommend adjustments or important lifestyle changes to patients to ensure successful scar correction and limit the formation of new scars. This may also cover recommendations on how to maximize immune response and minimize scar inflammation. Long-term management will cover the necessity to monitor the sites for any signs of infection, bleeding, or complications in the weeks and months after the revision. Many of the elements covered in this section complement the physical and emotional recovery sections since they are also concerned with what the patient can do for themselves to speed up their recovery time and reduce scar-related complications. In many cases, immediate and short-term self-care strategies are the same or similar across most scar revision procedures.
The field of scar revision is one that is constantly evolving; innovations in technology as well as the emergence of noninvasive or minimally invasive topically applied therapies have enabled clinicians to offer a wider range of treatments for patients with visible scarring. A number of trials and case reports have recently been published in this field, and we will describe these new treatments as well as innovations in surgery. The papers that we review in this section are mainly based on case reports, small case series, and work still in progress, and we will touch on some potential future directions in the field of scar revision surgery.
In summary, scarring is a common sequela of surgical procedures and can be distressing to patients. Scar revision practices have evolved over time to optimize the aesthetic outcome and can be nonsurgical and surgical in nature. Light-based therapy as one modality of noninvasive potential is an area of growing interest in the field of scar revision. In scar prevention, some reports suggest that early intervention with intense pulsed light after surgical intervention could aid in minimizing any potential permanent visual fibrosis. In particular, the use of 532-nm Q-switched neodymium-doped yttrium aluminum garnet lasers has proven efficacy in treating hypertrophic scarring and keloids and has led to new opportunities in the management of pathologic scarring post breast reconstruction as one relatively new modality in combination with traditional therapies.
Scars can be defined and classified in several ways, depending on the different focus points: surgical, histopathological, and so on. For clinical and/or etiopathogenetic purposes, it is convenient to classify them according to visual and palpable characteristics. Scars can be hypertrophic or atrophic. Another classification distinguishes normal scars, hypertrophic scars, and keloid scars. Hypertrophic and keloids are very different from each other. While hypertrophic scars can grow rapidly, stabilize, or regress of their own accord without invading the surrounding tissues, keloids grow pseudoinfiltrating tissues and continue indefinitely over time. Atrophic scars appear “sunken” and are the result of severe damage caused by the destruction of collagen and subcutaneous fats.
Excision is one of the oldest surgical techniques used to remove scars. It is used for stretched, wide, and atrophic scars. Outcomes are unpredictable, especially in the elderly. The subcuticular suture technique is useful to avoid rail tracking forward and is helpful to avoid new hypertrophic scarring. Dermabrasion is a good surgical alternative to obtain smooth scar tissue. A controlled study evaluated skin texture prior to the start of surgery and one year post-operatively. Laser therapy is used for diminishing scar redness and for remodeling scar tissue. Topical medication, cortisone creams, or 5-fluorouracil ointments are used for prevention of hypertrophic scarring after surgery. Intralesional injections of these substances, especially corticosteroids, in focal scar banding can also be considered.
Successful outcomes in surgical treatment and accrual should not be a specific end-point. The postoperative period is feared to affect diagnosis. Detailed informed consent is needed before the start of operative scar revision. Both further spread of current scar tissue and de novo scar formation should be part of this informed consent process. Recombinant growth factors, mesenchymal fibroblast injections, or mechanical control of dermal micro-wounds may benefit in the surgical treatment of raised scars. More controlled studies are needed to accurately confirm these issues. Proper use of surgical intervention to revise and manage a scar will bring patient complaints about their visual and emotional concerns near to end. However, precise surgical techniques can only give approximately 80% satisfaction. Some complications and contraindications need to be considered. A controlled improvement in outcome is necessary when additional surgical techniques are being developed.
Preoperative care. The surgeon should assess patient expectations and ensure their understanding of the surgical plan and postoperative wound care. A discussion of patient non-modifiable high-risk behaviors such as cigarette smoking will guide possible counseling and optimization strategies to mitigate associated risks.
Postoperative care. Wound care largely depends on the reconstruction and the complexity of each case; in general, patients should be instructed to avoid direct exposure of the surgical site to sunlight or extreme temperatures until the site starts to repopulate with natural melanocytes. Analgesics may be prescribed to aid initial pain management, but the use of non-steroidal anti-inflammatories should be carefully considered to avoid potentially negative effects on wound healing. Non-absorbable sutures are usually removed at postoperative day 5-10 to avoid suture tracts and associated scarring.
Complications. During the preoperative counseling process, patients should be informed of potential complications, such as hypertrophic scarring, wound breakdown, infection, hematoma, nerve injury, or recurrence of the scar. “Alar flaring” of the nares associated with placement of lateral alar flaps and widening of nostrils and tear duct stenosis are complications associated with paramedian forehead flaps and should be discussed in appropriate patients. Any new onset of pain, shortness of breath, headache, or other neurologic changes should prompt immediate patient evaluation.
Rehabilitation. Rehabilitation strategies may include patient instruction on modalities and exercise to reduce swelling, maximize strength, and improve facial symmetry. Physicians may recommend minimizing extreme facial expressions or massaging the forehead toward the nose post-brow lift to assist scar modification.
Patient education. Patient buy-in and understanding is essential for a successful reconstructive effort, especially for any cases of revision surgery. Compliance with preoperative and postoperative care has a crucial role in the ultimate surgical success.
Every single patient is different, and the recovery period generally depends on the person and the severity of the scar. Depending on the risk of keloid formation, oral steroids may be recommended postoperatively. Your board-certified plastic surgeon will give you a sense of how to best manage your recovery during your consultation and preoperative visit. In general, expect one week of minimal activity and 2 weeks of decreased activity before you’re feeling back to normal. Finally, keep in mind that all surgeries carry with them an element of risk.
Most patients may experience some discomfort from the wound following operative treatment, but this discomfort can be managed with medications. Strong pain relief will not be required for most patients.
Yes, most patients will notice a significant improvement within a week or two of having reconstruction completed. Although longer-term improvement may take a few months, the final results can last a lifetime. It is important, however, that the patient keeps in mind revision is unlikely to completely erase the scar. Scars are permanent, although they can be made to function and appear better. Additionally, the patient should consider that lifestyle changes and long-term sun protection will be necessary following treatment, as scarring will likely recur if the injury that caused the scar happens again.
THE FORM HAS BEEN SUCCESSFULLY SUBMITTED
Thank you for filling the form. Our call center team will call you soon through the number +90 850 460 57 24